With the proliferation of EMRs, many therapists have begun delegating their understanding of episode of care documentation regulations and requirements to their EMR developers. These software solutions provide innumerable benefits—and help significantly when it comes to maintaining compliance—but instead of relying on them so heavily, therapists should be using their EMRs as tools to improve their clinical practice through effective communication about their patients, their goals, and outcomes progress. To accomplish this, therapists must not only get comfortable with documentation best practices and policies by payer, but also acknowledge the role that excellent documentation plays in reflecting and improving clinical practice. Ultimately, effective documentation requires providers to accurately represent patient goals and effectively measure and record progress.
During this session, attendees will learn strategies for identifying and documenting the key elements that establish the uniqueness of a given patient episode and are necessary to collect payment. Following the session, attendees will be able to immediately apply the principles learned to effectively communicate patient goals and progress toward those goals using compliant and optimized documentation for Medicare and commercial payers—as well as ensure they can provide physicians and case managers with robust information about patient problems and goals and improve clinical practice through reflective documentation.
- Apply the ICF framework to organize clinical thinking and effectively select the outcome measures that best reflect the patient’s uniqueness.
- Implement a disciplined patient documentation process to improve patient care and clinical outcomes.
- Identify the patient-specific factors that influence the patient’s episode of care and distinguish how that makes the patient unique.